HLTH 3100 Week 7 Hospital Policy Review Example

Where the Advance Directive Policy Stops: A Close Reading of a Hospital Policy That Covers the Ordinary Case and Goes Silent When the Agent and the Directive Disagree

Student Name

Walden University

HLTH 3100: Ethical and Legal Issues in Healthcare

Instructor Name

Month Day, Year

Where the Advance Directive Policy Stops: A Close Reading of a Hospital Policy That Covers the Ordinary Case and Goes Silent When the Agent and the Directive Disagree

The Document Under Review

This review reads a community hospital's policy titled Advance Directives and Health Care Decision Making. The policy is a composite modeled on the structure of policies that many hospitals publish; it is not the policy of a named institution. It runs three pages and has five sections: purpose, definitions, procedures at admission, procedures during the stay and documentation. I read it clause by clause with one question: does it tell staff what to do in the situation this course has spent six weeks studying, when a patient can no longer decide and the person speaking for the patient disagrees with what the patient said before? The answer is that it covers the ordinary case well and stops exactly where that situation begins.

What the Policy Does Well

At admission. The policy requires registration staff to ask every adult patient whether they have an advance directive, to provide written information about the right to make health care decisions and to create advance directives, and to document the answer in the record. This tracks the federal Patient Self-Determination Act, which requires hospitals that participate in Medicare and Medicaid to give adult patients written information about their rights under state law to make decisions and formulate advance directives, to document in the record whether the patient has executed one and not to condition care on whether a patient has one (42 U.S.C. § 1395cc(f)). The policy's admission section meets each of these duties.

Definitions. The policy defines advance directive, living will, health care power of attorney and health care agent clearly, using the terms of the state's statute.

Ordinary procedures during the stay. When a patient loses capacity, the policy directs the physician to document the loss of capacity, identify the health care agent named in a power of attorney or, if none, the surrogate according to the state's priority list, and consult the advance directive. It states that the agent is to make decisions "in accordance with the patient's known wishes and values." For most patients, where the agent and the directive agree, this is enough.

The definitions also match the forms the hospital hands out at admission, which avoids a common source of confusion for families.

Where the Policy Stops

The policy contains one sentence about conflict: "Disagreements regarding treatment decisions should be referred to the attending physician." That is the whole of its guidance for the case where the agent asks for a treatment that the patient's directive or documented statements refused, as in last week's case of Mr. Chen, whose daughter requested a feeding tube despite his recorded wish to avoid tubes.

Read closely, the sentence leaves staff with nothing for that case. It does not say whose wishes govern when the agent and the directive conflict. It does not mention the ethics committee, although the hospital has one. It does not say whether treatment should start or wait while the disagreement is resolved, which matters for time-sensitive decisions like resuscitation. It refers the matter to the attending physician, who may be the person the agent is disagreeing with. And it says nothing about documenting the conflict or its resolution.

The policy's own definition section creates the gap. It defines the agent's duty as deciding "in accordance with the patient's known wishes and values," which implies that a request contrary to known wishes falls outside the agent's role. But the procedures never say what staff should do when that happens.

The Cost of Silence

The gap is not theoretical. Conflicts between surrogates and patients' earlier wishes are common enough that the course spent a week on them, and the research on surrogate accuracy suggests they will arise even with loving families (Shalowitz et al., 2006). Without guidance, the outcome depends on which physician is on duty and how comfortable that physician is with conflict. Some will defer to the agent to avoid confrontation; others will follow the directive without process. Either way, the patient's earlier decision is protected only by chance. Ethics frameworks hold that a surrogate's role is to represent the patient's wishes where they are known (Beauchamp & Childress, 2019), and a policy that defines the agent's duty that way should also tell staff how to act when the duty is not met.

Why Policies Stop Where They Do

Policy gaps of this kind are common because policies are usually written to satisfy a requirement, here the admission duties in the federal statute, and then amended only when something goes wrong. The admission section is detailed because surveyors check it. The conflict section is thin because no survey item tests it and, until a case like Mr. Chen's arrives, nobody notices. Reading a policy against the hardest case it will face, rather than the most common one, is the only way to find such gaps before they matter. For an administrator, this suggests a habit worth building: when a new policy is drafted, run it against two or three difficult scenarios drawn from real complaints or ethics consultations, and see where staff would be left without direction.

Suggested Additions

I would add a short section titled Conflicts Between the Agent and the Patient's Known Wishes, with four steps. First, the attending physician meets with the agent to review the directive or documented statements and explore what the agent understands the patient to have meant. Second, if the conflict continues, the physician requests an ethics consultation, which the policy should make available at any hour. Third, while the consultation proceeds, time-sensitive treatment decisions follow a stated default, for example continuing current treatment without starting new interventions the directive refused, unless delay would cause irreversible harm. Fourth, the conflict, the consultation and the resolution are documented in the record. These additions do not take authority away from agents. They give staff a path that respects both the agent and the patient, which the current policy leaves to chance.

References

Agreements with providers of services; enrollment processes, 42 U.S.C. § 1395cc(f) (2023).

Beauchamp, T. L., & Childress, J. F. (2019). Principles of biomedical ethics (8th ed.). Oxford University Press.

Shalowitz, D. I., Garrett-Mayer, E., & Wendler, D. (2006). The accuracy of surrogate decision makers: A systematic review. Archives of Internal Medicine, 166(5), 493-497. https://doi.org/10.1001/archinte.166.5.493